Health Service Helplines

8.1 p.m.

Lord Rowallan rose to ask Her Majesty's Government what is their long-term policy towards helplines in the field of health services.

The noble Lord said: My Lords, helplines have become synonymous with the upwardly mobile society of today. The better educated we become and the better health we enjoy, the more help we require from anonymous people at the end of a phone. All sections of our modern society--old and young, rich and poor--have problems, and we all know someone with more problems than ourselves. There has been a proliferation of new helplines to deal with every problem imaginable. Some are government led and funded; others are privately run and financed by charities. But all provide a vital service for many, many people too frightened, concerned or embarrassed to confront someone on a face to face basis.

The Department of Health runs 16 helplines, the best known of which are Childline, drinkline, aidsline and drugsline, but, interestingly, does not provide any service for the many people who want access to alternative medicines. The Government have also started up NHS Direct, a 24-hour advice line staffed by nurses and intended to cover the entire country by the millennium. Fourteen million pounds was spent on the pilot schemes in Milton Keynes, Preston and Newcastle-upon-Tyne. This year, £35 million is being put into the second phase covering 13 new areas and a further 19 million people. This month it has been announced that a single telephone line service is being installed at a cost of £4 million to put patients in touch with the full range of NHS services.

But is all this taxpayers' money being well spent? According to the Health Service Journal on 30th July this year,

"It is unclear how the new service fits in with existing primary care and information services offering telephone advice".

It seems that there were only 4,000 calls to the three pilots in 10 weeks. That is a very low uptake, being only 25 to 60 calls a day. Furthermore, when people were asked about the service in the pilot areas they said that they would use it for the following reasons: to get medical advice on minor ailments; to get medical advice if the GP was not present; to get advice as to whether they should go to accident and emergency, or the surgery; to get advice on self-help groups; to get information on patients' rights; or to get a second opinion. But they also said that they did not want the service if it took away from existing health services and that they would prefer to see a doctor in the first place. So there was not an enormous amount of enthusiasm from the public in these pilot areas, except for the secondary matters of health.

So could it be that the speed of the planned growth of NHS Direct suggests that the fulfilment of political promises precedes rigorous evaluation; or is it that the research is aimed at clarifying not whether NHS Direct develops but how? If this service is to develop, it must be at a very fast level for both the service itself and its

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nurses, both of whom will be on a steep learning curve. First, they must ensure that the service is safe and effective, especially in regard to the best processes to be used regarding which decision support software works best. Secondly, they must ensure that the service develops national standards rather than fragmented regional ones. Thirdly, they must ensure that the service is an integral part of the NHS itself. Fourthly, they must ensure that the service gives help to all. It must be wary of providing a service to those who do not need it because it is using such high technology. Fifthly, it must develop into more than just a helpline. It must become a forerunner for the future NHS whereby the system provides convenient and reliable interactive gateways to health and other welfare services such as managing chronic diseases, dispensing prescriptions and booking hospital appointments.

But--and this is the core question I am asking in this debate tonight--can and should this service be developed at the expense of, or separately to, the existing specialised helpline services already run privately by charities at great expense, with volunteers of enormous skill and specialised knowledge; or should it be integrated with them to provide a new dynamic package of care for those who need it?

I must declare an interest as a director of Sane, the mental health charity. I must also say how pleased we are to have a maiden speech from the noble Lord, Lord Harris of Haringey, whose contribution I much look forward to hearing; and I should like to say how delighted I am that five other noble Lords will be expressing their views on this vital subject.

There are approximately 1,000 existing helplines in the United Kingdom. In the field of health there are 108 dealing with general health matters, 53 with mental health problems, 140 with disabilities and 60 with sexual problems. I wish to concentrate on two of these helplines--Saneline and the Samaritans. Both work very well together and both provide a 365 day service, taking nearly 5 million calls a year between them. But both are being undercut by government funding going to new charities.

Saneline is not a referral service. It is committed to providing accurate and up-to-date information on options of care available in their own area. Callers who ring are stayed with throughout the time needed for the necessary help and support to be provided. Discipline is ensured by helpers, who get paid expenses only, each of whom receives 40 hours of training before starting work--a longer time than a good many social workers receive in the mental health field. Callers are put into a network of care and calls are followed up by a visit and/or a call back the following day. There are an average of 70,000 people phoning each year, averaging 800 hours a month of one-to-one contact. It costs Sane £900,000 a year to run. That is only three times what we are told the initial government investment in CALM--the Campaign Against Living Miserably--cost for its three month pilot scheme, which was restricted to Manchester and to 15 to 25 year-old men. As Sane already provides a specialised service for this group of people, I am forced to ask which organisation provides the better service and the better value.

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I ask the Minister to tell the House how she envisages that the nurses who are running NHS Direct will have the necessary knowledge to advise in anything other than generalised terms. It is obvious to me, and it should be obvious to this Government, that specialised nurses would be needed; and as there is a shortage of them already, where are they to come from? We certainly cannot afford to take them away from the frontline in the hospitals.

The latest government statement suggested that 15,000 nurses would be required to help run their current planned helplines, and this despite the current recruitment and retention crisis. So how can NHS Direct be serviced? If you are not providing specialisation, what happens if incorrect information is given? How many ordinary nurses know that 16 Lithium are fatal or that seven Paracetamol can kill; what drugs react badly with other drugs; and what are the side-effects of the new drugs coming on to the market? They are coming on all the time. They cannot, but Saneline's information data base of 13,000 records, which is continually updated, has all the information at the touch of a button for the carer, the doctor and the caller.

So why are CALM and NHS Direct created when the system to help these targeted people is already in place with a proven track record? This is duplication and may be a misuse of funds from other mental health services and the NHS generally. So I must ask whether the Government intend to audit the objectives, standards, outcomes and value for money given by both CALM and NHS Direct.

I turn to the Samaritans, which has been in existence since 1953. With 204 branches and 20,500 volunteers, it is the biggest of all helplines. It receives 4.5 million calls a year, of which 67 per cent. are from people contemplating suicide, and spends 3.3 million hours on the phone. It costs more than £1 million each year to run. Of all those calls, nearly 27,000 come from prisoners. They help to stop many suicides each year. The Government want them to continue to do that and yet they will not give them any help with funding the splendid work that they do. Recruitment is difficult. Now that the Government are intent on poaching volunteers and staff to the new lines that they are promoting and duplicating it will become harder.

I ask the Minister to answer the following questions. First, what are the Government's intentions with regard to the provision of helpline services for health-related matters and in particular the provision of emotional support for those in crisis taking into account the existing services and back-ups provided by the existing charities? Secondly, why is it no longer appropriate to provide financial assistance from central funds and Section 64 funding in particular in support of core costs for large existing and established voluntary organisations such as the Samaritans and SANE when at the same time the Government expect such organisations to play an active role in reducing suicides and improve the nation's mental health? Thirdly, are the Government prepared to acknowledge and use the significant resource that is available from the voluntary section to help achieve an improvement in the nation's

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health, mental and physical, and well being? Fourthly, are the Government aware of the need for a carefully co-ordinated strategy to address the incidence of suicide which in 1997 accounted for 5,712 deaths in Great Britain and untold distress for those who have been bereaved in this way? Fifthly, do the Government intend to keep on seeking new providers through advertising in obscure journals such as the supplement to the Official Journal of the European Communities and under the auspices of the Central Office of Information without contacting existing experts in these fields in order to give them a chance to bid for the franchise that they offer? Sixthly, can the privately financed charities have a guarantee that it is worth their while continuing to exist and to raise finances or do the Government intend to take over their functions? It is vital that those questions are answered in order that the existing charities can forward plan and budget. If the volunteers of the Samaritans and SANE were paid half the minimum wage that the Government have introduced, which would put them well below the poverty line, the cost to the nation would be over £14 million a year.

I earnestly request the Minister to work together with the established charities to provide for the health of our nation in a concerted and co-operative way but not in the confrontational and fragmented way that many of the charities feel is happening at the present time. I look forward to the noble Baroness's reply with great interest.

8.2 p.m.

Lord Harris of Haringey: My Lords, there are many traditions in this House. One of them is to feel nervous when making a maiden speech. I am not always a true believer in tradition, but I can confirm that this is a tradition that I am already following. Indeed, I now better understand that old story of the young boy who was taken by his father to an art gallery where they stopped in front of a large picture of "Daniel in the Lion's Den". And the little boy said, "Daddy, why is Daniel smiling?" and his father replied, "Well, you see, he doesn't have to speak during the dinner hour".

I take this opportunity to say how grateful I am to all of your Lordships for making me feel so welcome and to express my thanks to the staff of the House for being so helpful and supportive. I am also very grateful to the noble Lord, Lord Rowallan, for tabling his very interesting Question, thereby giving me the opportunity to intervene this evening.

I should declare my interest in this matter. I am a non-executive director of the London Ambulance Service NHS Trust and the LAS has been chosen to organise one of the second-wave NHS direct pilots. I should also record that I was until last month director of the Association of Community Health Councils for England and Wales and for a time was a trustee of the Help for Health Trust which runs some of the existing telephone health information services.

It is a truism that information is power. I hope it will not be taken in the wrong way by those of your Lordships who are or have been medical practitioners when I say that even now too many patients feel

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patronised by the professionals they encounter in the health service. However, whether those professionals like it or not patients are becoming empowered. The information revolution is going on around them. Patients are becoming better informed. They have access to more information and more sources of information. Some people already go into the consulting room having self-diagnosed themselves and already considered treatment options. They arrive in the presence of the doctor ready to negotiate their treatment--and, what is more, are capable of doing so. This will becoming increasingly common.

Medicine is not some mediaeval alchemy whose truths are jealously guarded by the lucky few inducted into its mysteries; nor even is it high science whose intricacies can be grasped only by a tiny minority. Much of the aura of medicine--hence much of the inequality between doctor and patient--is created by a differential access to information. We will see a gradual change in the role of the professional. When we go to see our doctor in the future we will not be consulting her or him as the provider of information about our condition, but increasingly our doctor will be the person who explains and interprets that information. That will change quite dramatically the balance of power between provider and user of services. Yet that is the direction in which the NHS must go, with the individual service user being an equal partner in determining his own care. That is why developments such as NHS Direct are so important. Not only is the service available whenever patients want it--24 hours a day and 365 days a year--but I also believe that it will help to reduce the burden on over-stretched GPs, hospital casualty departments and ambulance services. Patients will be able to get direct advice quickly and easily.

My understanding is that more than three-quarters of those who have rung the pilot NHS Direct lines have been advised to act differently from their pre-call intention. In many cases this has meant that a GP has not had to be called out, an emergency ambulance summoned, or time taken up in a busy accident and emergency department. There have also been cases--the converse, if you like--where it has been necessary to advise people to take more urgent action than would otherwise have been their intention. That is about potentially saving lives.

As I have no doubt already tried the patience of your Lordships with the length of this speech, I conclude with four questions that I hope the Minister can address later. First, what consideration is being given to meeting the needs of those with language difficulties or those for whom English is not their first language? Secondly, is it the intention that NHS Direct will in time supersede the existing telephone health information services--I do not mean simply those to which the noble Lord, Lord Rowallan, referred--or will they continue and operate in parallel? I believe that there would be benefits for patients if that happened. Thirdly, is it envisaged that patients and patients' representatives will be involved in evaluating the pilots and advising on the development of the service? Finally, as NHS Direct becomes a national

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service in the year 2000, what plans are there for publicising the service and will there be a single phone number for the country as a whole?

8.17 p.m.

Lord Dholakia: My Lords, I congratulate the noble Lord, Lord Harris of Haringey, on his excellent and thoughtful speech. His record in public service is second to none and we hope that in your Lordships' House he will have many more opportunities to make a contribution. I am well aware of his involvement in race relations. I am delighted that he identified one of these subjects in his speech. He was a member of the Home Secretary's Race Relations Advisory Committee. I am also involved in the field of mental health and am aware of his work in that sphere. I hope that he will be interested in what I have to say about the issues relating to race and the helplines. I give one word of warning to the noble Lord. I hope that he does not support his local team, Tottenham Hotspur. It is not a team that I support. If he does so, I shall be very unkind to him on future occasions.

I should like to thank the noble Lord, Lord Rowallan, for this important debate. Some time ago the noble Lord and I discussed this subject and we agreed on the need for a clear strategy on helplines. In a free and democratic society information plays a very important part and yet access to information is bound to be fairly limited. We are living proof of a society where at the touch of a few buttons on a computer we have access to information that would not have been possible a few years ago.

But there is a downside to the availability of information when it concerns the most intimate or personal details of individuals. Service providers are stretched to the limit and time constraints allow only limited access to those on whom we rely for such information. Often voluntary organisations are left to pick up the pieces because of limitations on service providers in the statutory sector. In almost all areas of public life the Government's strategy often relies upon the voluntary services to fill gaps left by the statutory agencies. No one can dispute that large numbers of voluntary organisations, in this case in the field of health, provide guidance and support by way of helplines. This involves the adequate training of volunteers and staff but also the production of printed information which is helpful to callers.

I have had a number of discussions with voluntary agencies working in the mental health field. It is all very well to equip organisations to start up a service by providing core grants. Saneline deals with a quarter of a million calls made by 70,000 people. The resource implications must be enormous, but there is a bottom line to such funding organisations receiving core grants, having established services, are now expected to be self-funding.

My noble friend Lord Clement-Jones will have more to say later on, but let me stress that the need for helpline services in the field of health is relevant to all sections of the community.

Britain is a multi-racial, multi-cultural society. The ethnic minority population forms about 5 per cent. of our total population. People from various parts of the

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world have made this country their homeland. Their welfare needs and language differ from the indigenous population. More importantly they have shared needs, special needs and separate needs in the field of health. Some of the health issues affect one or the other groups. Their comparatively short stay in this society does not lead them to use services with which they are not familiar. We need to establish that helplines cater adequately for their needs by providing services that are easily accessible and making sure that provision is made to use and train volunteers from these communities who are able to communicate with them.

Perhaps I may give an example. It is not directly relevant to the helpline in the health services but to racial attacks and racial incidents, of which there are an estimated 130,000 a year. Police forces were concerned about the low level of reporting. In a number of areas helplines were set up and manned by people with different languages. Suddenly, the level of reporting rose because people had confidence in being able to communicate in their own languages. The same applies in health services.

I believe that the effective provision of helpline services should attempt to meet the needs of our various communities by providing help, advice and literature in the language they understand. More importantly, it should cater for the needs of refugees, who are often the victims of serious human rights abuses and are desperately seeking help and advice relating to their health problems.

The gist of my case is that helplines can provide a crucial service to people with special needs, and in particular those who are under stress. Helplines could provide information not only to individuals with health needs but also to friends and relatives. Much more use should be made of ethnic press, radio and television programmes so that services are well advertised and easy to access.

What we require is a clear government strategy which provides a service of the necessary quality and which addresses the needs of all sections of our community. There ought to be adequate funding which will assist not only the survival but also the growth of voluntary helplines which are important for success in this field. There ought not to be duplication of services which are already provided and which afford a high standard of public satisfaction. Scarce resources ought not to be wasted.

Helplines, as demonstrated in other parts of the world, are a new and exciting service. We ought to build on the strength of existing organisations which have a proven track record in this field.

8.23 p.m.

The Lord Bishop of Lichfield: My Lords, my diocese covers a varied area of the West Midlands with a population of more than 2.5 million. It includes, for example, the Wolverhampton and Black Country together with the Stoke-on-Trent and Newcastle-under-Lyme conurbations. It also includes county towns such as Stafford and Shrewsbury, together

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with the many farming communities stretching from the Peak District in north Staffordshire to places such as Oswestry on the Welsh border. Some are remote communities.

I believe that, in principle, those who are aware of the helplines in the field of health services are strongly in favour of the kind of evidence which, for instance, the Health Minister, Mr. Milburn, shared with members of GP co-operatives at the conference in Warwick last month. It was evidence which the BMA also welcomed, though rightly insisting that it should be carefully evaluated; evidence, too, which, as we have heard from the noble Lord, Lord Rowallan, the Health Service Journal confirmed as broadly favourable. For example, at Warwick the Minister was able to tell us--and here I wish to be a little more positive about the pilot schemes and the evidence--that in the first three months of helpline pilot schemes 15,000 calls were made to the three NHS Direct pilot centres. Even more importantly, following the advice from trained nurses over the helplines, 30 per cent. of the callers were able to look after themselves at home rather than having to attend a GP's surgery or local casualty department. Surely that fact means a saving of NHS money and time and, as the previous speaker mentioned, avoids unnecessary stress on hard-pressed GPs.

I understand that in 200 cases callers needed emergency help, even though they were unaware of that when they first picked up the helpline, a point to which both the Minister and the noble Lord, Lord Dholakia, referred. At Warwick the Minister rightly claimed that a health service helpline can be a life saver. I also note that the helpline call centre equipment not only provides the means for patients and nurses or a doctor to talk to each other, but also allows for clinical decision support software to be used by the nurses as an aid in assessing and recording patients' symptoms in line with previous calls.

Other good considerations support the helplines trend in the health services. For example, primary care is available only at three access points; our GP, the casualty department of a local hospital or by dialling 999 for an ambulance. But, alas, as many of us know, an appointment with our GP may take a week or 10 days to arrange. A visit to a casualty department often involves a very long wait, as I have found. And many people do not want to call an ambulance on 999.

Sometimes the doctors tell us that we are not as seriously ill as we supposed. Talking through symptoms over a helpline can help us to realise that there is no immediate need for medical attention. Reassurance may be all that is required.

Furthermore, many families no longer live in close proximity and family advice is often no longer available. In many of the rural areas of my diocese transport services are few and far between. As I said, many people are unwilling to telephone for ambulances. Only last weekend I was speaking to a middle aged lady who cared for a very aged mother. The mother started an alarmingly bad nosebleed at three o'clock in the morning. They did not want to call an ambulance; they needed a health service helpline with the wise advice of a trained doctor or nurse.

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As we know, owing to increasing workloads, many GPs are frequently unavailable at weekends. We also hear of the alarming shortage of medical students. In fact, many medical practices are already offering their own health helplines in order to reduce the mounting workload.

A member of my own family has been suffering from Alzheimer's disease for the past 12 years. Because of the excellent work of our GPs, district nurses and care assistants, we are able to look after her at home. But not long ago she developed a chest infection which in turn triggered a severe convulsion. The convulsion caused a perforation of her bowel, which led to severe breathing difficulties which I did not understand. As a GP was not available on that occasion, I was obliged to wait five hours for a deputy doctor who arrived just before midnight. I was reluctant to ring for an ambulance as I did not know how serious her condition was. After another five-hour wait she was admitted at 6 a.m. the next day, some 12 or so hours wait in total. I believe that an NHS helpline with a trained nurse or doctor would have helped us greatly.

A further encouraging factor, which we have already heard from noble Lords is the proven value of the voluntary sector. That was also mentioned by the noble Lord, Lord Rowallan.

8.32 p.m.

Lord Mottistone: As chairman of SANE, I naturally wish to give added strength to the excellent speech of my noble friend Lord Rowallan who so splendidly introduced this debate.

Perhaps I may say to the right reverend Prelate that, yes, a helpline for the National Health Service is a good idea, but we are talking about helplines for the mentally ill. He was talking of wider issues. I know that he mentioned Alzheimer's disease, but nose bleeds are a different problem.

My connections with charities date from when I succeeded my mother as president of the NSPCC on the Isle of Wight. At that time, in the late 1970s, I wondered why we still needed charities to look after children. Were not the social workers, who had been established some 30 years before, going to do that? The answer was, "No, they cannot do it by themselves". One of the great features of the NSPCC which I discovered before I even touched on mental health is that it was able to be experimental, try new methods and help children ab initio without the public feeling that by going to it they were going to "auntie government". There is a reluctance by people to put their problems in the hands of government officials of whatever sort. That has nothing to do with party politics. People turn more readily to organisations such as the NSPCC than to social workers.

It is also a fact that, excellent though many social workers are, they are not quite so free to give treatment and to refer cases up the line quickly if they want to deviate from the norm. I discovered that that splendid charity, which had been in existence then for nearly 100 years and which is now much older than that, had a job to do in filling a gap. It still has that job to do and does it very well.

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I was asked to look after the interests in this House of the National Schizophrenia Fellowship. I readily backed that because it was a charity that had been created from the ground up. It had not been imposed by worthy people from above. I saw the possibilities of that charity because it could deal with matters flexibly. The Department of Health, in the early 1980s, was not really stuck into the problems of the mentally ill in the way that it had been involved with the mentally handicapped. It was doing its best but the mentally ill were a problem. People were trying to reduce the number of hospital beds because they had been told that would be a good idea. The whole matter seemed to me to be difficult.

I turn to SANE, an association of which I became chairman some 12 years ago. SANE started its Saneline because it received a lot of publicity. Its superb chief executive, Marjory Wallace, is a great publicist, apart from being a great fundraiser and a highly intelligent person who can pick up matters quickly when the need arises. We discovered that people ringing our ordinary telephone number wanted help, so we formed the helpline. Then we discovered that they needed more information than that with which we could easily put them in touch, so we developed a database. That database is unique in its form. I think that my noble friend Lord Rowallan touched on that. If he did not, I expect that the Minister knows enough about this matter to know that it is a uniquely well-balanced database manned by volunteers. Another aspect of helplines run by charities is that they are run, as far as possible, by volunteers on a day-to-day basis, with a few experts available for back-up where needed. That is the basis upon which the Samaritans was founded. That is a terribly good aspect of helplines.

We have a particularly good helpline which needs to be developed, not squashed. I believe that we should be encouraged to develop it more by having some of the extra money that I heard on television this evening is to be given to the Department of Health by the Chancellor of the Exchequer. That could be a good investment. As the right reverend Prelate indicated, if our helpline were given the support it needs, the health service could be spared trouble and expense.

8.36 p.m.

Lord Clement-Jones: My Lords, I welcome the initiation of this debate by the noble Lord, Lord Rowallan, and the valuable contribution of other noble Lords. In particular, I welcome what I thought was a shrewd contribution from the noble Lord, Lord Harris of Haringey.

My involvement with helplines stems from CancerBACUP, founded by my late wife, Dr. Vicky Clement-Jones. She was a bright, young 32 year old medical registrar and endocrinologist at Barts Hospital who was diagnosed with ovarian cancer in 1982. During the five remaining years of her life, she devoted herself to setting up CancerBACUP and its telephone Cancer Information Service. In its first 10 years of existence from 1985, when CancerBACUP was officially launched, it dealt with a quarter of a million telephone inquiries. It now deals with something like 45,000 inquiries a year and sends out some quarter of a million

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booklets. Yet, with 6,000 new diagnoses each week, if one other carer is included, it is reaching less than 10 per cent. of people who could benefit. CancerBACUP would certainly like to do much more to meet the need.

Vicky's motto was always, "Information is the antidote to fear". As a result, both CancerBACUP and I welcome the announcement of NHS Direct in last year's White Paper. In principle, I welcome the Government's commitment to roll out NHS Direct across the country and their resource commitment of something like £100 million annually. I also welcome the statements in Information for Health, the new NHS information strategy, that NHS Direct could be the stepping stone to a much wider future of telemedicine and telecare.

It is clear, however, that there are a number of concerns voiced by professionals and the voluntary sector in relation to NHS Direct which need to be allayed. Many of them have been expressed by noble Lords. Above all, there is the question of the relationship between NHS Direct and the specialist voluntary sector helplines. It is vital that NHS Direct works alongside existing voluntary sector helplines. It needs to make sure that optimum cross-referral to specialist services, whether for mental health problems, cancer or asthma, takes place, that duplication is avoided and that genuine co-working takes place. Only if NHS Direct sees its role as that of a gateway, not necessarily as a final point of destination, will the right relationship be built. NHS Direct must maximise the value of existing quality helpline resources in the voluntary sector.

If NHS Direct is used as a gateway, particularly if common telecommunications are used, the quality of service, both for NHS Direct and the voluntary sector, will be vital. They must operate within the same quality framework.

There are some 1,000 voluntary helplines across the UK but their quality differs widely. With the advent of NHS Direct, some kind of kite-marking or accreditation is needed which could follow the guidelines of good practice in telephone work drawn up by the Telephone Helplines Association. In that regard, as many noble Lords will know, the issue of confidentiality is absolutely vital.

Those helplines which are of sufficient quality, but only if they are, should be able to enter into service-level agreements with NHS Direct to provide specialist information, support and advice on referral. I would go further. For example, could not the Department of Health pilot arrangements between NHS Direct and suitable helplines over the next couple of years?

There are many other issues apart from those on which there is only time to touch briefly. Current funding of non-NHS helplines looks somewhat random. The information which the Department of Health has given me recently shows that that appears to be the case. What were the criteria for support of those helplines? I understand that the interim reports on the first pilots will be published by the Department of Health this

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December. But do we yet know enough about NHS Direct's effect on primary care services? Will it build on the extremely successful Wiltshire trial and the University of Southampton research? Why is the NHS not already developing draft national guidelines or protocols? At present, that will happen only at the beginning of the year 2000. Should not the second phase pilots be working next year, with draft national guidelines?

Will the £100 million pledge cover all the costs of those helplines of NHS Direct or will local trusts be expected to cover some of the costs? What are the recruitment implications? Those were touched on by the noble Lord, Lord Rowallan. There are estimates, which he mentioned, that another 15,000 nurses will be needed to provide a full national service for NHS Direct. In the face of a major recruitment crisis, with 8,000 nursing vacancies, will sufficient nurses be available to staff the service?

In the light of all the above, is the December 2000 deadline for national roll-out realistic? If those issues are resolved in time, I should be extremely happy to make sure that in due course NHS Direct becomes the third best-known telephone number in the country; that is, after people's home telephone numbers and 999. But the last thing any of us wants is for the service to fail because of over-hasty implementation and a lack of clear vision as to where it fits in with the voluntary sector.

8.43 p.m.

Earl Howe: My Lords, my noble friend Lord Rowallan deserves our thanks for presenting us with an opportunity to debate a subject which is both topical and of considerable interest to many in the medical world and outside. He covered a great deal of ground in his speech but I should like to underline and pursue one of the things which he touched on; namely, the development of NHS Direct.

NHS Direct was announced in last year's White Paper--The New NHS. The first wave of pilots in Milton Keynes, Northumbria and Preston was launched in late March 1998. It is a nurse-led scheme designed to act as a triage and information helpline for anyone wanting medical advice who lives within the scheme's designated area.

There is no doubt that such a scheme offers tremendous potential for fast-tracking patients to the advice or service which they need and for relieving the burden on GPs' surgeries. I welcome the fact that NHS Direct is nurse-led. As the Minister will know, the RCN has taken part in a three-year study with the University of Southampton to determine the safety and effectiveness of a nurse-led, out-of-hours telephone service. The results of that study, which were most encouraging, were published in the British Medical Journal on 17th October.

Emerging from that will be guidance on good practice for nurse telephone consultations and I am advised by the RCN that that guidance will be relevant to both NHS and privately operated services, including specialist health advice lines. The wish and aim of the RCN is to

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see a common standard applied both within the NHS and the independent sector to ensure that callers receive the right care in the right place at the right time.

Those developments are both welcome and timely. The RCN and Southampton University are to be congratulated on a useful and very satisfactory study. However, the leader of the research team stressed a key point; that to repeat the results achieved, the service must be planned and managed properly using experienced and specially trained nurses. That is where I return to NHS Direct. Thirteen second-wave pilots for NHS Direct have already been designated and we now understand that a third wave, bringing the national coverage to 60 per cent., will go live in February 2000.

That begs a very large question: what analysis and evaluation have been carried out on the three initial pilots to validate and inform the setting up of the second and third waves? It appears that the Department of Health has chosen not to wait for the results of the first three pilots before rolling out the scheme on a very much wider scale. On what basis has that been done? At the very least, we need to have a clear picture of the number of patients directed to their GP or to an A&E department and data on outcomes. To the extent that interrogation through NHS Direct results in an increase in the number of patients sent to GPs and A&E units, we need to know how appropriate those referrals turn out to be. If it emerges that most patients are ill and in need of attention, that is well and good. But if what is happening is simply that a greater number of worried well people are filling up surgeries and delaying examination of urgent and ill patients in hospital casualty departments, then very serious questions will need to be asked. We simply do not know.

I ask the Minister what measures of evaluation are being used by the Government to assess the cost-effectiveness of NHS Direct? What are the key tests for its success or failure? The Minister of State, Mr. Milburn, was quoted recently as claiming that NHS Direct is proving to be a lifesaver, as the right reverend Prelate mentioned. The apparent basis for that statement was that 220 callers to the service had been recommended to seek an ambulance even though the callers themselves had not recognised the urgency of their inquiries. But Mr. Milburn does not seem to have considered that either patients may be overplaying their symptoms on the telephone or the nurses may be adopting an extremely cautious approach. What matters for evaluation purposes is not whether the ambulance was called, but whether it was justified when the patient arrived at hospital.

GPs are worried that NHS Direct, far from reducing the workload in surgeries, may be increasing it unnecessarily. I am aware that primary care co-operatives in Preston and Milton Keynes have expressed their worries about a rise in inappropriate out-of-hours referrals and have voiced their impression that the nurses manning the helplines are working with flawed protocols which are being followed rigidly, with the result that there is no separation of the urgent cases from the non-urgent. I ask the Minister whether those worries are being taken seriously by her department and whether, in particular, the health authorities' steering

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committees charged with rolling out the scheme across the country will be encouraged to take the opinions of local GPs fully into account as they proceed.

As the RCN has emphasised, the key to success is thorough and appropriate nurse training. I should be grateful for any information which the Minister can give me on the training that nurses are receiving.

There is also another dimension; that is, the long-term effect of NHS Direct on GP co-operatives. A few weeks ago, the Government made the welcome announcement of an increase in funding for the out-of-hours development fund in England. As the Minister will be aware, there are increasing calls on that fund from a growing number of GP co-operatives. It is highly valued. Yet she will know also that fears persist among GPs that that money may be diverted to fund the expansion of NHS Direct. Can she offer any reassurance on that point?

I believe that NHS Direct and GP out-of-hours co-operatives should be regarded as complementary services. If triage nurses were linked directly with doctors available to provide emergency advice and visits, that would indeed make for a seamless and fast-track service. But that is not how NHS Direct is being set up. By and large, it operates independently of co-operatives. I repeat, I believe NHS Direct to be a service with great potential if handled properly, but it appears to have been rushed and, so far at least, it seems to be fuelling unnecessary demands rather than managing existing demand better. I hope that the Minister will be able to offer some reassurance.

8.49 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hayman): My Lords, I add my thanks to the noble Lord, Lord Rowallan, for initiating tonight's short debate which, although it has been short, has been of high quality. It is certainly proving a challenge in terms of responding in 12 minutes to all the issues that have been raised. I shall do my best to answer most of the questions, but perhaps I may write to noble Lords on those questions that I am forced to leave out because of shortage of time.

We also should be grateful to the noble Lord for eliciting a very thoughtful and well-judged maiden speech from my noble friend Lord Harris of Haringey. He comes to this House with the strongest of track records, both in local government and in the health service. His contribution tonight made us aware why he has that track record. He made us all look forward to the ongoing contribution he can make to the proceedings of this House.

Many issues have been raised tonight about the general strategy regarding helplines. There has been some very specific focusing, particularly in the area of helplines in the voluntary sector and those dealing particularly with mental health services.

As a Government we are committed to providing health services that are fast, convenient and responsive. We recognise the crucial role which good information and advice have to play in helping patients and their carers to manage successfully the consequences of

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illness as well as to ensure more appropriate and effective use of services and to help reduce inappropriate demands on the NHS.

Information can help to bridge the gap between professional knowledge and patient anxiety. I take on board the point raised by the noble Lord, Lord Clement-Jones, that we must have some quality assurance about the information provided. I believe that he will be reassured by the focus on the new information strategy for the NHS; that is, the importance of making sure that quality assurance in relation to health and illness is maintained.

The telephone has a particularly crucial role to play in helping to improve our access information. It is far from being a new medium. However, it has reached the stage in the UK where it is virtually a universal medium and where most of us are increasingly familiar with using the telephone to access information and services on a variety of issues. However, I take note of the issue raised by the noble Lord, Lord Dholakia, that we have to make sure that we relate to the whole population and that we provide telephone services that are accessible, particularly to newcomers who do not have the same kind of experience with telephone information services--for example, refugees. There has to be some sensitivity to those issues and to issues affecting ethnic groups.

I was at the Royal College of Nursing yesterday at the Mary Secole Awards. It was interesting to hear a past award winner talk about her project with patients in Sickle Cell Crisis. She referred to the number of calls she had received which had nothing to do with Sickle Cell Crisis. About 25 per cent. related to general health issues. Perhaps I should not mention the 2 per cent. of calls that were from people asking for their shopping to be done. I can identify with that as well.

As has been pointed out in the debate tonight, a wide range of telephone helplines operate in the health field and do an excellent job providing access to information, advice and reassurance. The Department of Health supports wholly or in part over 20 telephone helplines, which cover a wide range of health issues. High profile services have been mentioned such as Childline, national AIDS and Drugs Helplines. We also provide support for the National Asthma Helpline and Quitline, offering confidential and practical help on giving up smoking. We know also of the very fine work that is done by organisations like Cancer BACUP and of course, because of the particular commitments of the noble Lords, Lord Rowallan and Lord Mottistone, the service offered by Saneline. The Government very much welcome the valuable work done by organisations such as SANE and the Samaritans in providing telephone support and advice to people with mental health problems. They do an excellent job and help a great many people, often in very difficult circumstances. I am very happy to pay tribute to that work today. Saneline meets a clearly established need which the Department of Health has recognised by providing funding of around £830,000 over the past five years, including £225,000 of direct help for Saneline. This year we are also contributing over £29,000 for the London Helpline for

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management and volunteer training. Clearly, it is a valued service which we would all like to see continue and flourish.

Equally, we recognise the important role of the Samaritans, particularly at times of personal crisis or when people may be at risk of suicide. In their Healthier Nation Green Paper the Government pledged to commit themselves to improve the health of the nation and to address the incidence of suicide. We are proposing a target to reduce the death rate from suicide and undetermined injury by at least one-sixth by the year 2010. If that is met, nearly 800 lives will be saved.

The noble Lord, Lord Rowallan, asked whether we had the strategy in place. Focusing on high-risk groups is part of the Government action to reduce the overall suicide rate. Because of concern over suicide in certain high-risk occupational groups, particularly among farmers, the department has commissioned research into suicide and to self-harm in those groups in particular.

Noble Lords will have seen how much of tonight's debate has focused on the issue of NHS Direct, a new service which has been introduced, and its interaction with established and specialist services. I recognise the concerns which exist as regards the specialist services and the roll-out of the service and its evaluation. That has been mentioned by speakers on both Front Benches. I was particularly grateful for the welcome given by the right reverend Prelate the Bishop of Lichfield to the service and his acknowledgement of the number of people and variety of circumstances that, by its generalist nature, NHS Direct is able to help.

We look to NHS Direct not only to use the technology to respond positively to the needs of patients, but to enable the public to make better use of NHS services. I am not as gloomy as the noble Earl, Lord Howe, about the possibilities of and potential for misuse. I believe that the potential for focusing people in the right places is enormous. If people have reassurance that they do not need to be in the A&E department at all, it means that those awaiting admission will have to wait a lot less than five hours. The NHS professionals can then concentrate their efforts where they are needed.

By next year we shall have launched a second wave of pilot areas and extended coverage to 20 million people, or more than 40 per cent. of the population. The second wave will include a number of major population areas, including the whole of Greater Manchester, most of the West Midlands conurbation and most of the West Country. In those pilot schemes we shall have to address the issues of the interface, particularly with local services directed at minority ethnic communities.

As regards the new pilot schemes which have been announced, I can reassure the noble Lord, Lord Howe, that GP co-ops are involved in six of the 13 second-wave areas. In one case in west London they are providing a central call centre for the service. In others they are part of the hub-and-spoke model, with some out-station nurse triage in the GP co-ops, which are networked into a central call centre.

So we are looking very carefully at the possibilities of the interface between GP services and those offered by NHS Direct. We have to be careful that providing

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a service in one place does not create greater demand elsewhere. I also have to evaluate carefully what is being done. The concept of a national network helpline is new and the first-wave pilot sites are being independently evaluated by the medical research unit at Sheffield University to explore how they operate, the benefits they bring, their costs, what effects they have on NHS services and the lessons that may be learnt for NHS Direct. We are taking a developmental approach, making sure that we learn the lessons and evaluate properly but at the same time do not lose the impetus of rolling out the programme which is necessary.

The noble Earl, Lord Howe, asked about accessibility for those with language difficulties and for whom English is not their first language. We are committed to ensuring that it is accessible for people with special communication needs. We want to see how the extensive work we need to undertake can best be organised within a national service.

We want to look too at the evaluation to make sure that patients and their representatives will be involved. Included in the membership of the National Advisory Group for NHS Direct are the patients association, the CHC chief officer as well as representatives of the mental health interests--to which I should now like to turn--and the interface between NHS Direct and the issue of specialist helplines.

We believe that, in the longer term, we fully expect there to be a continuing need for other specialist telephone services after NHS Direct has become established as a national service. Indeed, one of the advantages of NHS Direct will be a single and, over time, very well known telephone number which the public will recognise not only as a quick and reliable route to information and advice on a wide range of health issues--as the right reverend Prelate said--but also as a gateway to other services and other providers of information. It seems quite likely, therefore, that NHS Direct, far from taking over the role of specialist helplines, will have the effect of promoting them by referring more people on to them.

Thus, as NHS Direct develops, there will be the opportunity to build up links with other specialist helpline providers so that callers can be passed on seamlessly, in some cases without the need to redial, to other sources of help. The objective of NHS Direct is to provide first line help and advice. It should not take over the role of the specialist. What it can do is to provide far better signposting for the public who otherwise might not be able to locate easily specialist sources of information. We are keen to work closely with specialist helplines in developing NHS Direct. Both the Telephone Helpline Association and the Samaritans are represented on the National Advisory Group for NHS Direct.

I do not have time to deal with any of the other issues except to say that I believe the possibilities offered by NHS Direct of going even wider into all sorts of other areas like telephone booking of appointments and access to other services is enormous. I understand the need that has been stressed for proper evaluation and to make sure that we do not undermine services that already exist.

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However, there is an impatience to move forward because there is an enormous potential for improving the speed, quality and accessibility of information services to patients in this country.